Local coverage determination requirements not inconsistent with national requirements

A Medicare administrative contractor (MAC) properly denied claims submitted for cardiac monitoring services because they were not supported by the documentation required by the local coverage determination (LCD). A Florida district court upheld the denial of 16 of Medicomp, Inc’s claims, finding that the MAC’s LCD did not conflict with the binding national coverage determination (NCD) requirements (Medicomp, Inc. v. U.S. Department of Health and Human Services, March 3, 2016, Antoon, J.).

Claims. Medicomp supplies remote cardiac monitoring services to Medicare patients. Patients wear a cardiac event monitor prescribed by a physician for up to 30 days, and the device informs the patient to contact Medicomp’s monitoring center when a recorded heart rate is clinically significant. The device emits a series of beeps, which Medicomp records over the phone then decodes through an electrocardiogram (EKG). Medicomp provides the report to the ordering physician, and submits claims to Medicare as an independent diagnostic testing facility (IDTF). The MAC initially denied 27 of these claims in 2011 due to insufficient documentation, and Medicomp appealed. Sixteen claims remained in dispute at the district court level.

Required documentation. HHS relied on the LCD documentation requirements issued by the MAC when denying payment. Medicomp argued that this reliance was in error, and that by applying the LCD, HHS disregarded an NCD. It stated that the LCD is impermissibly more restrictive than the NCD, which requires reimbursement for these remote monitoring services.

The LCD in question requires that an ordering physician submit medical record documentation to the MAC that indicates the medical necessity of the monitoring service for the diagnosis billed, including documentation of a pre-service EKG and EKG rhythm strip. Medicomp argued that these requirements are not consistent with the clinical rationale or the NCD’s statement that some episode of arrhythmia may not be detected using an EKG. However, the court found that this note did not render the LCD’s requirement of such documentation inconsistent with the NCD. The court found Medicomp’s arguments to be a challenge of the validity of the LCD, which is not permitted before an administrative law judge (ALJ) or the appeals council. Such LCD challenges must be properly brought under 42 C.F.R. §426.300 et seq. by either a beneficiary or the beneficiary’s estate. The court affirmed HHS’ decision.

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